1986, 09-04 Permit App: 00012954 Piping, Plumbing FixturesLL_)
7
16130 A44
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Owner's Name Last
First
IProject M
�2�5L
MI
Project Address (Street Name
City
Assessors Parcel
Applicant
Subdivision/Plat Name
Address
State
Business Phone
Phone
Business Phone
Describe Work
Bar Sink(s):
Dsh Wehr(s):
Urinal(s):
Other:
Waste/Grease Interceptor(s):
Drinking Fountain (s):
Floor Drain (s):
Lndry Tray(e):
Sew Eject(a):
Bidet (e):
Drains -Roof:
REPAIR OR ALTERATION:
Drainage, Vent, Water Piping/Treatment:
Lawn Sprinkler System (s), Including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of line 16: 1-5:
(:-AS P/It L 3
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including Inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state of local laws regulating construction or the performance of
;onstruction.
SIGNATURE OF
)WNER OR AGENT
(Or) S+:
APPLICATION
DATE